Abstract
This article describes a review of articles on productive aging published in the American Journal of Occupational Therapy (AJOT) during 2012 in light of the Centennial Vision charge of supporting practice through evidence. Seventeen AJOT articles published in 2012 specifically addressed productive aging. Of 6 Level I studies, 4 were systematic reviews that identified effective occupational therapy interventions for community-dwelling older adults; 1 randomized controlled trial examined the effectiveness of writing life reviews for residents of senior residences, and 1 meta-analysis investigated the effectiveness of fall-related efficacy and engagement in activity or occupation. Two Level II studies and 2 Level III studies produced support for the effectiveness of individual and group-based occupational therapy interventions. Of 7 descriptive studies addressing a variety of areas, 4 addressed the reliability and validity of assessments. In 2012, AJOT published more and higher quality studies addressing a variety of issues related to productive aging.
The Centennial Vision target date of 2017 is a mere few years away. This vision created a road map to the future of occupational therapy and will commemorate the American Occupational Therapy Association’s (AOTA’s) 100th anniversary. The vision statement projects a healing profession that “is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p. 613). As we strive to fulfill the vision and follow the road map created, we continue to measure our progress along the way. To that end, the American Journal of Occupational Therapy (AJOT) annually assesses its success in accomplishing the goal of increased quantity and quality of the research studies it publishes. AOTA’s mission as stated in the Centennial Vision is to promote research that supports the effectiveness of occupational therapy services. Such research includes
Effectiveness studies supporting practice,
Instrument testing to establish reliability and validity for occupational therapy assessments,
Correlational and descriptive studies that demonstrate links between occupational engagement and health,
Studies that answer important questions about topics related to the direction of the profession’s growth, and
Basic research studies that provide information about disabilities and their impact on functional participation (Gutman, 2008).
Also contained in the Centennial Vision is a call to sustain existing practice areas while embracing new and emerging practice areas to meet society’s needs. Productive aging is one of the practice areas singled out for examination (AOTA, 2007; Baum, 2006). In this review, I evaluate the progress of AJOT articles related to productive aging published during 2012.
Method
Sharon Gutman, the editor of AJOT, screened all research articles published or accepted for publication in AJOT during 2012. She identified 17 articles related to productive aging practice, which represented approximately 20% of all research studies published. I read and reviewed the 17 articles on the basis of my broad experience in productive aging, occupational therapy, and evidence-based practice. I categorized the articles according to the AOTA Evidence-Based Literature Review Project Levels of Evidence Rating System (Lieberman & Scheer, 2002). This model standardizes and ranks the value of scientific evidence for biomedical practice using the following grading system (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996):
Level I: Systematic reviews, meta-analyses, or randomized controlled trials (RCTs)
Level II: Two groups, nonrandomized studies (e.g., cohort, case control)
Level III: One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV: Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V: Case reports and expert opinion that include narrative literature reviews and consensus statements.
In addition, I evaluated the articles using criteria Gutman provided and summarized them in Table 1.
Summary of Evidence From 2012 Productive Aging Studies
Note. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.
Findings
Effectiveness Studies
Ten effectiveness studies related to productive aging were published in 2012. These studies included 4 systematic reviews, 1 RCT, 1 meta-analysis, 2 two-group nonrandomized controlled studies, and 2 pretest–posttest single-group studies.
Three systematic reviews found moderate to strong evidence for the effectiveness of occupation- and activity-based interventions. Arbesman and Mosley (2012) and Orellano, Colón, and Arbesman (2012) conducted systematic reviews that evaluated and synthesized the evidence for interventions commonly used in occupational therapy to restore, modify, and maintain performance of instrumental activities of daily living (IADLs) in community-dwelling older adults. Whereas Arbesman and Mosley focused specifically on performance in health management and maintenance, Orellano et al. focused specifically on occupation- and activity-based interventions for IADLs in general. Both studies found strong support for client-centered occupation-based interventions. Arbesman and Mosley found moderate evidence that self-management programs are effective; that educational programs for clients, caregivers, and health professionals improve health management in older adults; and that skill-specific training is more effective when combined with health management programs. Orellano et al. found moderate support for vision rehabilitation interventions to improve IADL performance, with mixed evidence noted for physical activity and cognitive performance skills training.
Stav, Hallenen, Lane, and Arbesman (2012) found strong evidence that engagement by older adults in social activities and physical activity sustained occupational performance and decreased decline and that older community-dwelling adults who were not socially or physically active experienced greater mortality and decreased performance.
Two Level I studies (1 systematic review, 1 meta-analysis) and 1 Level III study focused on the effectiveness of interventions related to fall prevention. Chase, Mann, Wasek, and Arbesman (2012) explored the impact of fall prevention programs and home modifications on falls and the occupational performance of community-dwelling older adults. They found strong evidence for the effectiveness of multifactorial programs that included home modifications, physical activity or exercise, education, vision and medication checks, and assistive technology. They also found moderate evidence for the effectiveness of programs that provided physical activity or home modifications.
Schepens, Sen, Painter, and Murphy (2012) conducted a meta-analysis that examined the relationship between fall-related efficacy and measures of activity and participation in community-dwelling older adults. Participants who had higher fall-related efficacy had fewer falls and higher levels of activity function and performance, including performance of daily tasks.
Elliott et al. (2012) conducted a Level III study that examined the feasibility of conducting interdisciplinary fall risk screens at a community-wide adult fall prevention event and investigated whether people who attended the event made home or activity modifications. They found that providing interdisciplinary fall risk screens at an adult fall prevention event can prompt older community-dwelling adults to modify their environments and behaviors to reduce fall risk.
Two studies explored culturally based occupational therapy interventions. Hersch et al. (2012) conducted a Level II quasi-experimental study that looked at the effectiveness of providing culturally relevant, occupation-based intervention to facilitate the adaptation of older adults who had recently moved to a long-term care facility. Haltiwanger (2012) conducted a one-group pretest–posttest pilot study that evaluated the effectiveness of a structured, culturally sensitive, peer-led group program with indirect occupational therapy supervision to improve diabetes self-management in Mexican-American older adults. Both studies concluded that providing culturally relevant occupational therapy improved participants’ quality of life and adherence to health maintenance and self-management.
Two studies examined specific occupational therapy interventions in limited contexts. O’Brien, Bynon, Morarty, and Presnell (2012) conducted a two-group nonrandomized controlled study to determine the impact of a newly developed targeted occupational therapy intervention, a function conditioning program, on length of stay, discharge destination, resource use, and functional status of older adults admitted to an acute care hospital posttrauma. The researchers found significant differences in length of stay, initiation of therapy, and return to home rates. Also noted were increased occupational therapy referrals for participants in the functional conditioning program group compared with control group participants who received standard care.
Chippendale and Bear-Lehman (2012) conducted an RCT to explore the effect of writing a life review on the depressive symptoms of older adults residing in senior residences. Residents who attended the most sessions of this occupation-based intervention, titled Share Your Life Story, demonstrated the most improvement in Geriatric Depression Scale scores.
Descriptive and Correlational Studies and Basic Research
Seven descriptive studies were published in 2012. Four addressed instrument development and testing. One explored the inclusion of low vision rehabilitation content in occupational therapy curricula. Another study explored the relationship between fear of falling and depression, anxiety, and activity participation. In addition, a scoping review was conducted to summarize the literature on occupational therapy’s involvement in fall prevention intervention.
Painter et al. (2012) conducted basic research, a correlational study examining the relationship between fear of falling as measured by the Survey of Activities and Fear of Falling in the Elderly (SAFE) and scores from the Geriatric Depression Scale–30 and the Hamilton Anxiety Scale–IVR. Correlation analyses among these measures found relationships between fear of falling and depression, anxiety, and activity level; depression and anxiety; and activity restriction and depression for community-dwelling older adults.
Directions for the Profession’s Growth and Education
Deacy, Yuen, Barstow, Warren, and Vogtle (2012) explored the curricula of occupational therapy and occupational therapy assistant programs in the United States for low vision rehabilitation content. Almost 40% of 314 programs responded to the survey. All of the programs that responded had some level of low vision rehabilitation content delivered in their curriculum. Only 25 programs included a required course with a primary focus on low vision rehabilitation. Content about low vision rehabilitation varied widely across curricula, even when specialists within the program or from the community provided the training.
Leland, Elliott, O’Malley, and Murphy (2012) searched the literature for studies that were conducted by occupational therapists or that included occupational therapy intervention related to fall prevention. They identified 15 such studies, 6 from Australia and 9 from the global occupational therapy community; 12 were RCTs. The studies addressed occupational therapists providing home modifications, home assessments, patient education, activities of daily living performance interventions, exercise interventions, and multidisciplinary programs for individuals or groups. Leland et al.’s analysis indicated that occupational therapists are not providing the full scope of practice as outlined in the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008). They advocated that occupational therapists consider facilitating medication management, managing postural hypotension, managing existing foot problems and recommending footwear, and recommending behavioral modifications as part of intervention. They concluded that occupational therapists need to conduct further research about fall prevention and to include interventions from the full scope of practice.
Instrument Development and Testing, Occupational Engagement, and Health
Three of the four studies related to instrument development focused on the psychometric properties of assessment tools in development. One study focused primarily on investigating the differences in perception of the assessment tool respondents based upon Toglia’s (2011) Dynamic Interactional Model of Cognition.
Classen and colleagues (2012a, 2012b) conducted two studies examining the Safe Driving Behavior Measure (SDBM). One study quantified the rater reliability and rater effects using item response theory among three groups of raters—older drivers, family caregivers, and driving evaluators—and found that the evaluators were more severe in their rating of older drivers than family caregivers or the older drivers themselves (Classen et al., 2012b). The second study explored the item and person psychometrics of the SDBM using the same three groups for comparison (Classen et al., 2012a). The SDBM had good construct validity in measuring perceived safe and unsafe driving behaviors and good reliability in differentiating the scores of the test respondents; however, the authors noted the need for further refinement of some items. Both studies identified the need for further research.
Hwang (2012), who developed the Health Enhancement Lifestyle Profile (HELP; Hwang, 2010), conducted a psychometric study of the reliability of the HELP–Screener, a short form of the HELP. Test–retest reliability and construct reliability for a convenience sample of community-dwelling older adults who had not been institutionalized were in the acceptable to very good range.
Katz, Averbuch, and Bar-Haim Erez (2012) compared clients with stroke with healthy control participants to examine the reliability and validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment—Geriatric Version (DLOTCA–G). They found that interrater reliability and internal consistency were in the acceptable to good range but that the memory section requires further research and refinement. The dynamic aspect of the assessment involved the effect of mediation of learning using Toglia’s (2011) Dynamic Interactional Model of Cognition, and both groups made gains after mediation.
Discussion
The AOTA collaboration developed for systematic reviews continues to provide the bulk of Level I effectiveness studies. Levels II and III effectiveness studies involving productive aging made a stronger showing in 2012 than in previous years (D’Amico, 2012; Murphy, 2010, 2011). The strong support these studies (even those not conducted by occupational therapists) provide for occupation-based and client-centered intervention to promote productive aging validates the foundational tenets of our profession. This validation enables other health care providers and society to recognize the value we provide to clients.
Research on productive aging published in AJOT in 2012 identifies opportunities for the occupational therapy profession:
Models demonstrating the importance and value of occupational therapy in promoting desirable patient and hospital outcomes demonstrate the efficacy of occupational therapy in improving health care outcomes (O’Brien et al., 2012).
Cultural relevance has been a cornerstone of occupational therapy since its inception, and studies supporting this aspect of occupational therapy remain important within the broader framework of health care (Haltiwanger, 2012; Hersch et al., 2012).
Community events such as health fairs provide a means to improve safety and health and assess potential changes that may result from community-based education (Painter et al., 2012).
The profession may need to consider standards related to curricula content about low vision rehabilitation (Deacy et al., 2012).
Falls prevention is a major area related to occupational performance that requires more attention within the context of practice and research (Chase et al., 2012; Elliott et al., 2012; Leland et al., 2012; Painter et al., 2012; Schepens et al., 2012). Existing research has predominantly been produced by occupational therapists in Australia and other parts of the world.
Although the areas of driving rehabilitation and assessment, falls prevention, and low vision rehabilitation have been around for many years, these topics have a continued and needed presence as the U.S. population ages and life expectancy around the world increases (Classen et al., 2012a, 2012b).
Studies addressing the validity and reliability of assessments developed by occupational therapists, including the SDBM (Classen et al., 2012a, 2012b), the HELP–Screener (Hwang, 2012), and the DLOTCA–G (Katz et al., 2012), increased in 2012. The continued refinement of assessments ensures the current potential and continued use of each tool. Assessments created by occupational therapists for occupational therapists are great, but assessments created by occupational therapists that have the potential to become standards in their specialties would be a tremendous boon to the profession, especially in the areas of driving, community living, and functional cognitive performance.
All studies demonstrated limitations, often related to small sample sizes, lack of replicability, limited diversity among samples, and lack of long-term follow-up. Although some studies supported the effectiveness of interventions within the scope of occupational therapy practice, many studies in the systematic reviews and scoping review revealed that few such studies are being conducted by occupational therapists.
Implications for Occupational Therapy Practice
This review has the following implications for occupational therapy practice:
Further evidence is available of the power of occupation-based and activity-based interventions in improving occupational performance.
Prevention services and programs provided in the community can improve health, well-being, and continued occupational performance and participation for older adults.
Community health fairs provide opportunities for practitioners, educators, and students to provide services and collect data.
Cultural relevance is an important element of client-centered interventions with older clients.
Fall prevention interventions should address exercise, home modifications, foot care and footwear, medication management, postural hypotension, and fear of falling.
Occupational therapy practitioners are encouraged to develop or identify programs and interventions that improve client performance and outcomes.
Conclusion
In 2012, AJOT articles related to productive aging practice increased 30% over previous years (2009–2011). The increased quality and quantity of such articles promise continued growth in the journal’s impact ratings. Although, as noted in several studies, much research remains to be done, this progress reflects “our unique and invaluable contributions to health care and societal needs, for which no other profession could ever substitute and [ensures] reimbursement streams to support the skillful and complex work we do every day” (Clark, 2011, p. 618).